Primary hyperparathyroidism in developing world: a systematic review on the changing clinical profile of the disease

ABSTRACT While the developed world is focusing on laying guidelines for selecting out cases of Asymptomatic primary hyperparathyroidism (PHPT) for surgical intervention and promoting minimal access surgery, the developing world is observing a change in disease spectrum from advanced symptomatic to lesser degree of symptomatic disease and not many with associated Vitamin D deficiency. Few studies from the developing countries of the world have focused on the changing clinical spectrum of PHPT. Objective of this study is to review the changing profile of PHPT in developing world. A systematic literature search was done in December 2017 focussing on publications from the developing world. All studies pertaining to the epidemiology of PHPT published after 1st January 2000 and published in English language were included for analysis. Most of the studies published from developing countries report a predominance of symptomatic disease (79.6% of all included patients) with musculoskeletal disease present in the majority of patients (52.9%). The combined mean serum total calcium (11.9 ± 1.4 mg/dL), serum PTH (668.6 ± 539 pg/mL), serum alkaline phoshpatase (619 ± 826.9 IU/L) and weight of excised parathyroid glands (4.4 ± 3.8 grams) are much higher than those reported from the western studies. Despite this, we found that there is a distinct trend towards a milder form of disease presentation and biochemical profile noticeable in more recent times. Although there is a striking difference in all aspects of PHPT disease epidemiology, clinical presentation and biochemical profile of developing and developed countries, there is a distinct trend towards a milder form of disease presentation and biochemical profile in more recent times.

Experience with a third-generation parathyroid hormone assay (BIO-PTH) in the diagnosis of primary hyperparathyroidism in a Brazilian population

ABSTRACT Objective To evaluate the usefulness of a third-generation PTH assay in the diagnosis of primary hyperparathyroidism (PHPT). Subjects and methods Forty-one PHPT patients (4 men and 37 women) with 61.2 ± 10.9 (mean ± SD) years, were studied and had PTH levels measured with two different methods using the same immunochemiluminescent assay plataform (Elecsys 2010 System, Roche). We compared a second-generation assay (I-PTH) with a third-generation PTH assay (Bio-PTH). Two populations of 423 and 120 healthy adults with serum 25OHD levels above 25 ng/mL were used to define normal values in the I-PTH and Bio-PTH assays respectively. Results Normal PTH values based in the healthy adults population were 24.2-78.0 pg/mL for the I-PTH assay and 19.9-58.5 pg/mL for Bio-PTH assay. In PHPT patients, PTH values ranged from 67 to 553 pg/mL (median: 168 pg/mL) using the I-PTH assay and from 55 to 328 pg/mL (median: 111 pg/mL) using the Bio-PTH assay. Results obtained with the Bio-PTH assay were significantly lower (p < 0.0001, Wilcoxon). In general I-PTH and Bio-PTH showed highly significant correlation (r = 0.952, p < 0.0001). Passing–Bablok analysis gave a regression equation of Bio PTH = 13.44 + 0.59 x intact PTH. PHPT patients had 25OHD levels ranging from 4 to 36 ng/mL (mean 16.2 ng/mL); 35 subjects (85.3%) had values bellow 25 ng/mL. Conclusion Our results demonstrate that both second and third generation PTH methods are strongly correlated in PHPT patients and control subjects. Lower results with Bio-PTH tests are expected in function of the assay specificity determined by the amino-terminal antibody used.

Importance of careful Tc-MIBI interpretation in patients with thyroid cancer and primary hyperparathyroidism

No abstract available.

Normocalcemic primary hyperparathyroidism: long-term follow-up associated with multiple adenomas / Hiperparatireoidismo primário normocalcêmico associado a múltiplos adenomas

Normocalcemic primary hyperparathyroidism (NPHPT) is a condition characterized by elevation of the parathyroid hormone (PTH) in the presence of normal serum calcium and the absence of secondary causes. The case described illustrates the long-term follow-up of a postmenopausal woman with NPHPT patient who progressed with multiple adenomas. This case reports a 77-year-old female who has chronic generalized pain and osteoporosis. Her initial serum PTH was 105 pg/mL, with total serum calcium of 9.6 mg/dL, albumin 4.79 g/dL, phosphorus 2.8 mg/dL, and 25OHD after supplementation was 34.6 ng/mL. The bone densitometry (BMD) results were as follows: lumbar spine: T-score -3.0, femoral neck: T-score -2.6 and distal radius: -4.2. Other causes of secondary hyperparathyroidism were ruled out and cervical ultrasound and Tc-99-Sestamibi scan were negative. She used oral alendronate and three infusions of zoledronic acid for treatment of osteoporosis. In the 10th year of follow-up, after successive negative cervical imaging, ultrasound showed a nodule suggestive of an enlarged right inferior parathyroid gland. PTH levels in fluid which was obtained during fine-needle aspiration (FNA) were over 5,000 pg/mL and a Sestamibi scan was negative. The patient underwent parathyroidectomy, and a histological examination confirmed parathyroid adenoma. Post-operatively serum PTH remained elevated in the presence of normal serum calcium levels. A follow-up cervical ultrasound showed a new solid nodule suggestive of an enlarged right superior parathyroid gland. PTH levels in the aspiration fluid were remarkably high. A second parathyroidectomy was performed, with the excision of a histologically confirmed parathyroid adenoma. In conclusion, this is an unusual presentation of NPHPT and highlights the long-term complications.

Hiperparatiroidismo primário normocalcêmico (NPHPT) caracteriza-se pela elevação do hormônio da paratiroide (PTH), na ausência da elevação dos níveis séricos de cálcio e exclusão de causas secundárias. O caso descrito ilustra o seguimento de uma mulher na pós-menopausa com NPHPT que evoluiu com múltiplos adenomas. Este caso relata uma paciente de 77 anos de idade que tem dor generalizada crônica e osteoporose. O PTH inicial foi elevado com níveis séricos de cálcio, albumina, fósforo e 25OH vitamina D normais. A densitometria óssea (DMO) evidenciou um T-SCORE da coluna lombar: -3.0, colo do fêmur: -2.6 e rádio distal: -4.2. Outras causas de hiperparatireoidismo secundário foram descartadas e a ultrassonografia cervical e varredura com Sestamibi foram negativos. Fez uso de alendronato e três infusões de ácido zoledrônico para o tratamento da osteoporose. No décimo ano de seguimento, depois de sucessivas imagens negativas, a ultrassonografia evidenciou um nódulo sugestivo de adenoma de paratireoide inferior direita. A paciente foi submetida à paratireoidectomia, e um exame histológico confirmou a hipótese. A elevação dos níveis séricos de PTH no pós-operatório se manteve com níveis normais de cálcio. A nova ultrassonografia cervical evidenciou outro nódulo sugestivo de adenoma de paratireoide superior direita. Uma segunda paratireoidectomia foi realizada, cujo histológico confirmou outro adenoma de paratireoide. Conclui-se que essa é uma apresentação incomum de NPHPT e destaca as complicações a longo prazo.

Correlación entre el nivel preoperatorio de paratohormona y el volumen y peso del adenoma de glándula paratiroides extirpado, en pacientes con hiperparatiroidismo primario mejorados / Correlation of preoperative parathormone level with estimated volume and weight of the parathyroid adenoma in patientes with primary hyperparathyroidism

Introducción: El hiperparatiroidismo primario (HPT1°) es la causa más frecuente de hipercalcemia en la población ambulatoria general. Así mismo, es la indicación más frecuente de cirugía paratiroídea, habitualmente causado por la presencia de un adenoma único, que se asocia a un elevado nivel de paratohormona (PTH). Objetivo: Determinar si existe una relación matemática positiva entre el nivel de PTH preoperatoria y el volumen y peso del adenoma extirpado. Material y Método: Se revisaron retrospectivamente los resultados de las biopsias y PTH preoperatoria de 71 pacientes evaluables con diagnóstico de HPT1° por adenoma único, mejorados. Resultados: Se obtuvo una correlación matemática positiva, aunque débil, entre peso, volumen y PTH preoperatoria. La correlación matemática fue positiva y fuerte entre peso y volumen. Conclusiones: Existe una relación positiva débil entre el peso y volumen y los niveles preoperatorios de PTH. Estos aspectos estudiados son útiles pero especialmente en relación con otros hallazgos pre e intraoperatorios.

Background: Primary hyperparathyroidism is caused mostly by a single adenoma and it is the most frequent cause of hypercalcemia in outpatients. Hyperplasia of the four glands and cancer are the other ethiological diagnosis. It has been postulated that the bigger and heavier an adenoma is the higher the preoperative PTH level. Objective: To evaluate a mathematical relation between adenoma estimated volume and weight and preoperative parathormone level (prPTH). Method: Retrospective analysis of 71 evaluable treated patients biopsies and preoperative PTH level. Results: A mathematical positive and weak correlation between volume, weight and preoperative PTH was obtained. This correlation was positive and strong between volumen and weight. Conclusions: In this group we found a positive and weak mathematical relation between weight, volume and preoperative PTH levels. These aspects alone are useful but only in combination with others for the correct interpretation of pre and intraoperative findings.

Tratamiento del hiperparatiroidismo primario mediante abordaje mínimamente invasivo / Treatment of the primary hiperparatiroidism by minimally invasive boarding

The unilateral boarding of the primary hiperparatiroidism constitutes a technical option increasingly secondhand and adapted for the characteristics of this surgery. This type of boarding has been possible for the appearance of the Tc sestamibi, of the subspecialization of the surgery and of the determination of the PTH intraoperatory. Later we expose an epidemiological, descriptive and retrospective study from january 2004 to December 2008. During this time there were controlled in the hospital Ramon and Cajal of Madrid a total of 195 patients for primary hiperparatiroidism. Of them, 140 were submitted to unilateral exploration by suspicion of the solitary adenoma. The correlation between the findings of Tc sestamibi and surgical was correct in all the cases (139) except one concerns to right or left side. It failed in 30 cases in which there was detected badly the top and low location. As for the results the adenoma was extirpated correctly in 135 of 140 patients. This way we can say that the combination of the gammagraphy, a surgeon with experience and the support of the PTH intraoperatory they meet a high rate of treatment in case of adenomas in the unilateral boarding on a rate of hipercalcemia appellant or persistently between 3 percent-5 percent, rate similar to the obtained one for expert surgeons on having fulfilled an exploratory cervicotomy (considered "gold standard") but with minor postoperatory morbidity, minor pain and minor surgical time.

El abordaje unilateral del hiperparatiroidismo primario constituye una opción técnica cada vez más usada y apropiada debido a las características de esta cirugía. Este tipo de abordaje ha sido posible por la aparición del Tc sestamibi, de la subespecialización de la cirugía y de la determinación de la PTH intraoperatoria. A continuación exponemos un estudio epidemiológico, descriptivo y retrospectivo desde enero de 2004 a diciembre de 2008. Durante este tiempo fueron intervenidos en el hospital Ramón y Cajal de Madrid un total de 195 enfermos por hiperparatiroidismo primario. De ellos, 140 fueron sometidos a exploración unilateral por sospecha de adenoma único. La correlación entre los hallazgos gammagráficos y quirúrgicos fue correcta en todos los casos (139) menos uno en cuanto a lo que a lateralidad se refiere. Falló en 30 casos en los que se detectó mal la localización superior e inferior. En cuanto a los resultados, se extirpó el adenoma correctamente en 135 de los 140 pacientes. Así podemos decir que la combinación de la gammagrafía, de un cirujano con experiencia y el apoyo de la PTH intraoperatoria proporciona una elevada tasa de curación en el caso de adenomas paratiroideos en el abordaje unilateral con una tasa de hipercalcemia recurrente o persistente entre el 3 por ciento-5 por ciento, tasa similar a la obtenida por cirujanos expertos al realizar una cervicotomía exploradora (considerada gold standard) pero con menor morbilidad postoperatoria, menor dolor y menor tiempo quirúrgico.

Normocalcemic primary hyperparathyroidism in clinical practice: an indolent condition or a silent threat? / Hiperparatireoidismo primário normocalcêmico na prática clínica: condição indolente ou ameaça silenciosa?

OBJECTIVE: To describe the characteristics of normocalcemic primary hyperparathyroidism (NPHPT) in patients seen for osteoporosis evaluation. PATIENTS AND METHODS: We examined the records of 156 women who came to the hospital to be screened for osteoporosis. Measurements of total calcium, PTH, 25-hydroxy vitamin D, and β-C-telopeptide were recorded. Bone mineral density and T-scores were evaluated by densitometry of the lumbar spine, femoral neck and distal one-third of the radius. The latter was only measured in patients with primary hyperparathyroidism. Nephrolithiasis and bone fractures were documented by a review of the medical records. RESULTS: We identified 14 patients with NPHPT, accounting for 8.9 percent of the population studied. In the medical records, the occurrence of kidney stones was reported in 28.6 percent of the patients with NPHPT, in contrast with only 0.7 percent of the noncarriers. Regarding the presence of general fractures, 21.4 percent of the patients with NPHPT were affected versus 16.2 percent of noncarriers. CONCLUSION: Data from our study suggest that NPHPT has a diverse phenotypic presentation, implying that this may not be an "indolent" disease.

OBJETIVO: Avaliar as características do hiperparatireoidismo primário normocalcêmico (HPTPN) em pacientes atendidos para avaliação de osteoporose. PACIENTES E MÉTODOS: Foi realizada análise de um banco de dados de 156 mulheres que procuraram atendimento para avaliação de osteoporose. Todas apresentavam dosagem de cálcio sérico, PTH, 25-hidroxi-vitamina D e C-telopeptídeo. A densidade mineral óssea e escore-T foram avaliados por meio de densitometria óssea de coluna lombar, colo do fêmur e rádio distal, este último apenas em pacientes com hiperparatireoidismo renal primário. Nefrolitíase e fraturas ósseas foram documentadas pela revisão dos prontuários. RESULTADOS: Foram identificadas 14 pacientes com HPTPN, correspondendo a 8,9 por cento da população estudada. Nos registros médicos, o relato da existência de litíase renal ocorreu em 28,6 por cento dos portadores de HPTN em contraste com apenas 0,7 por cento nas mulheres não portadoras, com um p < 0,001. CONCLUSÃO: Os dados do estudo sugerem que HPTPN tem uma apresentação fenotípica variada, podendo não ser uma patologia "indolente".

Transitory increase in creatinine levels after parathyroidectomy: evidence of another action of the parathyroid glands? / Alteração transitória da creatinina após paratireoidectomia: evidência de outra ação das glândulas paratireoides?

OBJECTIVE: Little information is available on glomerular function changes after surgical treatment of primary hyperparathyroidism. The acute effects of some head and neck operations on renal function were studied. MATERIAL AND MATHODS: Retrospective analysis of changes in creatinine levels and estimated glomerular filtration rate (eGFR) after surgery. Preoperative values were compared with values available until 72 hours after the operation. RESULTS: In tertiary hyperparathyroidism, mean preoperative and postoperative eGFR values were 57.7 mL/min and 40.8 mL/min (p < 0.0001), respectively. A similar decrease was observed after parathyroidectomy for primary hyperparathyroidism, from 85.4 mL/min to 64.3 mL/min (p < 0.0001). After major head and neck procedures, there was a slight increase in eGFR (from 94.3 mL/min to 105.4 mL/min, p = 0.002). CONCLUSION: Parathyroidectomy may be followed by a transient decrease in eGFR that is not often observed in other head and neck operations.

OBJETIVO: Há pouca informação sobre alterações da função glomerular após o tratamento cirúrgico do hiperparatireoidismo primário. O efeito agudo sobre a função renal foi estudado após algumas operações em cirurgia de cabeça e pescoço. MATERIAIS E MÉTODOS: Análise retrospectiva dos níveis de creatinina e da taxa de filtração glomerular estimada (eGFR). Os valores pré-operatórios foram comparados aos valores disponíveis até 72 horas após a operação. RESULTADOS: No hiperparatireoidismo terciário, os valores médios pré e pós-operatórios da eGFR foram 57,7 mL/min e 40,8 mL/min (p < 0,0001), respectivamente. O decréscimo após paratireoidectomia por hiperparatireoidismo primário foi de 85,4 mL/min para 64,3 mL/min (p < 0,0001). Após operações maiores de cabeça e pescoço, houve leve elevação da eGFR (de 94,3 mL/min para 105,4 mL/min, p = 0,002). CONCLUSÕES: A paratireoidectomia pode ser seguida de uma redução transitória na eGFR que não é frequentemente observada após outras operações em cabeça e pescoço.

Hiperparatiroidismo primario con normocalcemia, una asociación de diagnóstico complejo: a propósito de un caso clínico / Normocalcemic hyperparathyroidism: report of one case

We report a 59 years old female with a history of nephrolithiasis and progressive worsening of her bone mineral density. High serum PTH levels were detected, with normal serum calcium. Causes of secondary hyperparathyroidism were discarded. The patient was followed during six years, period in which she maintained elevated serum PTH and normal serum calcium. During the second year of follow up, hydrochlorothiazide was indicated. Serum calcium raised progressively and after six years, it became abnormally high. The patient was subjected to a total left lobe and subtotal right lobe thyroidectomy. The surgeon found a 1.6 mm diameter left parathyroid nodule. After surgery the patient is asymptomatic and is receiving levothyroxine supplementation.

Normocalcemic primary hyperparathyroidism / Hiperparatiroidismo normocalcêmico primário

Primary hyperparathyroidism is a common disorder of mineral metabolism characterized by incompletely regulated, excessive secretion of parathyroid hormone from one or more of the parathyroid glands. The historical view of this disease describes two distinct entities marked by two eras. When primary hyperparathyroidism was first discovered about 80 years ago, it was always symptomatic with kidney stones, bone disease and marked hypercalcemia. With the advent of the multichannel autoanalyzer about 40 years ago, the clinical phenotype changed to a disorder characterized by mild hypercalcemia and the absence of classical other features of the disease. We may now be entering a 3rd era in the history of this disease in which patients are being discovered with normal total and ionized serum calcium concentrations but with parathyroid hormone levels that are consistently elevated. In this article, we describe this new entity, normocalcemic primary hyperparathyroidism, a forme fruste of the disease.

O hiperparatiroidismo primário (HPTP) é uma doença comum caracterizada por uma regulação inadequada da secreção do paratormônio em uma ou mais glândulas paratiroides. Historicamente a doença pode ser dividida em duas eras. Quando o HPTP foi descoberto há 80 anos, era sempre sintomático com nefrolitíase, doença óssea e acentuada hipercalcemia. Com o advento das rotinas laboratoriais por autoanalisadores bioquímicos há 40 anos, o fenótipo clínico mudou para uma doença sintomaticamente leve na ausência daqueles achados clássicos. Está se entrando numa terceira era em que os pacientes são diagnosticados com calcemia normal na presença de níveis circulantes elevados do paratormônio. Neste artigo, descreve-se essa nova entidade, hiperparatiroidismo primário normocalcêmico, uma forma frusta da doença.

Utilidade da medida de PTH intra-operatório no tratamento cirúrgico do hiperparatiroidismo primário e secundário: análise de 109 casos / Usefulness of intraoperative PTH measurement in primary and secondary hyperparathyroidism: experience with 109 patients / Usefulness of intraoperative PTH measurement in primary and secondary hyperparathyroidism: experience with 109 patients

INTRODUÇÃO: A medida de PTH intra-operatório (PTH-IO) foi inicialmente descrita em 1988, sendo potencialmente útil na definição de sucesso após a paratiroidectomia. OBJETIVOS: Avaliar prospectivamente perfil de decaimento do PTH-IO e sua capacidade de prever sucesso cirúrgico no hiperparatiroidismo primário (HPP) e secundário à insuficiência renal (HPS). PACIENTES E MÉTODOS: 109 pacientes operados entre 06/2000 e 12/2004, sendo 33 HPP, 76 HPS (52 em diálise, 24 transplantados renais). PTH-IO: método imunométrico rápido (Elecsys-PTH/Immunoassay-Roche); tempo para resultado: 10 minutos. Coletas de sangue periférico nos tempos basal, 10 e 20 minutos pós-paratiroidectomia. RESULTADOS: HPP: queda média de PTH de 79,2 por cento aos 10 minutos. HPS: queda média de PTH de 85,8 por cento e 87,6 por cento aos 10 minutos nos pacientes diálise e transplantados respectivamente. A cirurgia foi bem sucedida em todos, exceto em 2 pacientes (1 HPP, 1 HPS). Em ambos não houve queda PTH-IO, sendo constatado adenoma duplo no HPP e paratiróide ectópica no HPS. CONCLUSÃO: Medida PTH-IO fornece resultados confiáveis em tempo rápido, sendo capaz de discriminar persistência da doença se mantidos níveis elevados.

INTRODUCTION: Intraoperative parathyroid hormone measurement (IO-PTH) was first described in 1988 and it's potentially useful in predicting cure after parathyroidectomy. The aim of this study was to evaluate IO-PTH decay profile and the utility of this procedure in predicting cure in primary (PHH) and secondary (SHH) hyperparathyroidism due to renal disease. PATIENTS AND METHODS: 109 patients were evaluated from 06/2000 to 12/2004. 33 had PHH and 76 SHH (52 in dialysis, 24 with renal graft). IO-PTH was measured at times 0 (before resection), 10, 20 minutes after parathyroidectomy using immunometric assay (Elecsys-PTH/Immunoassay-Roche). Time necessary to perform assay: 10 minutes. RESULTS: HPP patients: IO-PTH average decrease 79.2 percent from basal levels after 10 minutes. HPS: IO-PTH average decrease 85.8 percent and 87.6 percent after 10 minutes in dialysis and renal graft patients respectively. All patients were cured, except 2 (1 PHH, 1 SHH), because of a double adenoma and ectopic (mediastinal) parathyroid respectively. Failure in IO-PTH decrease was observed in both. CONCLUSION: IO-PTH measurement is useful in improving surgical success rates in PHH and SHH.

Asymptomatic primary hyperparathyroidism / Hiperparatiroidismo primário assintomático

Primary hyperparathyroidism is a common disorder of mineral metabolism characterized by incompletely regulated, excessive secretion of parathyroid hormone from one or more of the parathyroid glands. In adults with the disease, a single, benign adenoma is seen approximately 80 percent of the time, with multiple gland involvement comprising most of the remaining patients. Very rarely, a parathyroid cancer is responsible but it is seen in less than 0.5 percent of patients with primary hyperparathyroidism. In this article, we will review important clinical and diagnostic features of asymptomatic primary hyperparathyroidism as well as considerations for surgical or medical management of the disease.

O hiperparatiroidismo primário é uma distúrbio comum do metabolismo mineral, caracterizado por um excesso de secreção do hormônio das paratiróides, de uma ou mais glândulas paratiroidianas. Nos pacientes adultos portadores da doença, um adenoma único é responsável por aproximadamente 80 por cento dos casos, e o envolvimento de múltiplas glândulas pelo restante dos casos. Muito raramente um câncer de paratiróide é a causa, sendo visto em menos de 0,5 por cento dos pacientes com hiperparatiroidismo. Neste artigo, revisaremos as características clínicas e diagnósticas do hiperparatiroidismo primário assintomático, bem como o tratamento clínico e cirúrgico.

From mild to severe primary hyperparathyroidism: the Brazilian experience / Do hiperparatiroidismo primário leve ao severo: a experiência brasileira

Primary hyperparathyroidism often presents as an asymptomatic disorder. In our institution, routine serum calcium measurements have now been used as part of medical examination for 23 years. Out of 124 patients consecutively seen at our institution, 47 percent presented with no symptoms related to the disease, while 25 percent presented with severe skeletal involvement and osteitis fibrosa cystica, 25 percent with renal stone disease without overt bone involvement, and 2 percent with the typical neuropsychiatric syndrome. This same pattern is seen in the city of São Paulo. In severe disease pathological fractures are frequently seen, especially in long bones of the lower extremities, and also loss of lamina dura of the teeth and salt-and-pepper appearance of the skull. Bone mineral density is extremely low in these patients but usually show remarkable recovery following surgical cure. Serum PTH and bone markers are considerable higher in severely affected patients, who also have a high rate of vitamin D deficiency, and the parathyroid lesion is easier located compared with asymptomatic patients. From pathological specimens 87 percent had histological confirmation of a single adenoma, 6.4 percent multiple gland hyperplasia and 3.8 percent carcinoma.

Na maioria dos relatos da literatura recente, o hiperparatiroidismo primário apresenta-se, com freqüência, na forma assintomática. Em nossa instituição utilizamos a determinação rotineira do cálcio sérico há 23 anos. Em nossa série de 124 casos consecutivos, 45 por cento não apresentavam sintomas relacionados com a doença, 25 por cento tinham envolvimento esquelético intenso com osteíte fibrosa cística, 25 por cento tinham nefrolitíase sem envolvimento ósseo severo, e 2 por cento apresentavam a síndrome neuro-psiquiátrica típica. Esse mesmo padrão tem sido observado na cidade de São Paulo. Na doença severa são freqüentes as fraturas patológicas, especialmente nos ossos longos dos membros inferiores, como também a reabsorção da lâmina dura dos dentes e o aspecto em "sal e pimenta" nas radiografias do crânio. A densidade mineral óssea mostra-se extremamente reduzida nesses pacientes, mas em geral exibe melhora marcante após a cura cirúrgica. O PTH no soro e os marcadores bioquímicos da remodelação óssea estão significativamente mais altos nos pacientes com doença severa, os quais freqüentemente apresentam deficiência de vitamina D e localização mais fácil da lesão paratiroideana, quando comparados aos pacientes assintomáticos. Ao exame anátomo-patológico, 87 por cento tiveram confirmação de adenoma único, 6,4 por cento hiperplasia glandular difusa e 3,8 por cento carcinoma.

Relação entre os níveis séricos de cálcio e paratormônio e a positividade da cintilografia das paratiróides com sestamibi: análise de 194 pacientes / The relation between serum levels of calcium and PTH and the positivity of parathyroid scintigraphy with sestamibi: analysis of 194 patients

Com o objetivo de correlacionar os níveis séricos de cálcio e PTH com a porcentagem de resultados positivos na cintilografia das paratiróides (CP), analisamos retrospectivamente 194 pacientes submetidos à CP. Avaliou-se visualmente a distribuição dos resultados das CP em um diagrama de dispersão cujos eixos eram os níveis de cálcio (eixo Y) e PTH (eixo X) séricos. Foram definidos 6 grupos de pacientes: 1) cálcio > 12mg/dL; 2) 11mg/dL < cálcio < 12mg/dL; 3) 9,9mg/dL < cálcio < 11mg/dL com PTH > 120pg/mL; 4) 9,9mg/dL < cálcio < 11mg/dL com 65pg/mL < PTH < 120pg/mL; 5) 9,9mg/dL < cálcio < 11mg/dL com PTH < 65pg/mL; e 6) cálcio < 9,9mg/dL. A porcentagem de exames positivos nestes 6 grupos foram respectivamente: 10/10 (100 por cento), 18/29 (62 por cento), 7/9 (78 por cento), 18/45 (40 por cento), 2/21 (10 por cento) e 1/80 (1 por cento). Em conclusão, nos pacientes com suspeita de hiperparatiroidismo primário, as CPs realizadas antes da cirurgia de paratiroidectomia naqueles com níveis de cálcio acima de 11mg/dL são, na maioria das vezes, positivas. Para pacientes com níveis de cálcio sérico entre 9,9mg/dL e 11mg/dL, a pertinência da realização da cintilografia vai depender dos níveis de PTH sérico, sendo esta pertinência alta para pacientes com níveis de PTH acima de 120pg/mL e muito baixa para pacientes com PTH abaixo de 65pg/mL. Pacientes com cálcio sérico abaixo de 9,9mg/dL raramente apresentam cintilografia das paratiróides positivas.

Changes in clinical and laboratory findings at the time of diagnosis of primary hyperparathyroidism in a University Hospital in São Paulo from 1985 to 2002

In contrast to most developed countries, most patients with primary hyperparathyroidism in Brazil are still symptomatic at diagnosis. However, we have been observing a change in this pattern, especially in the last few years. We evaluated 104 patients, 77 females and 27 males aged 11-79 years (mean: 54.4 years), diagnosed between 1985 and 2002 at a University Hospital. Diagnosis was made on the basis of clinical findings and of high total and/or ionized calcium levels, high or inappropriate levels of intact parathyroid hormone and of surgical findings in 80 patients. Patients were divided into three groups, i.e., patients diagnosed from 1985 to 1989, patients diagnosed from 1990 to 1994, and patients diagnosed from 1995 to 2002. The number of new cases diagnosed/year increased from 1.8/year in the first group to 6.0/year in the second group and 8.1/year in the third group. The first group comprised 9 patients (mean serum calcium ± SD, 13.6 ± 1.6 mg/dl), 8 of them (88.8 percent) defined as symptomatic. The second group comprised 30 patients (mean calcium ± SD, 12.2 ± 1.63 mg/dl), 22 of them defined as symptomatic (73.3 percent). The third group contained 65 patients (mean calcium 11.7 ± 1.1 mg/dl), 34 of them symptomatic (52.3 percent). Patients from the first group tended to be younger (mean ± SD, 43.0 ± 15 vs 55.1 ± 14.4 and 55.7 ± 17.3 years, respectively) and their mean serum calcium was significantly higher (P < 0.05). All of symptomatic patients independent of group had higher serum calcium levels (12.4 ± 1.53 mg/dl, N = 64) than asymptomatic patients (11.4 ± 1.0 mg/dl, N = 40). Our data showed an increase in the percentage of asymptomatic patients over the years in the number of primary hyperparathyroidism cases diagnosed. This finding may be due to an increased availability of diagnostic methods and/or to an increased awareness about the disease.